Respondents reported that Choosing Wisely recommendations had been integrated in a number of ways including being implemented in clinical care (n = 817; 72.9%), through development of a specific clinical protocol or institutional guideline (n = 736; 65.7%), through development of specific electronic medical record (EMR) orders (n = 626; 55.8%), or with integration of longitudinal tracking using an electronic dashboard (n = 213; 19.0%). Some respondents identified that a specific quality improvement initiative was developed related to the Choosing Wisely recommendations (n = 468; 41.7%), or that a research initiative had been conducted (n = 156; 13.9%) (Supplemental Fig. 1, Supplemental Digital Content 1, http://links.lww.com/CCM/E138; legend: ways in which the Choosing Wisely recommendations have been implemented).
Over 300 open-ended comments revealed a number of ways that the Choosing Wisely recommendations have been integrated (Table 1). Review of these responses were grouped into broad categories including changes made to order sets, development of specific policies or guidelines, orientation information to new employees; changes in recommendations for transfusions; use of less volume blood draw tubes; use of palliative care triggers; evaluation of nutrition in the ICU; decreasing sedation and reducing delirium initiatives; tracking of utilization by practitioner; EMR order set changes; EMR reminders for transfusion restrictions; development of standard operating procedures concerning transfusions, laboratory orders, sedation, palliative care and nutrition; use of an ICU checklist to reinforce reducing unnecessary diagnostic testing; educational campaigns initiated, among other initiatives.
One respondent reported “We have a protocol for sedation and spontaneous awakening and spontaneous breathing trials and liberation from mechanical ventilation. We have a protocol and checklist for ordering blood products, and we are working on reducing diagnostic tests. We also created a palliative care team to offer/discuss comfort care.” Another shared “We have a robust interdisciplinary Quality Improvement committee that has led efforts for each of the critical care Choosing Wisely recommendations. We have done the most work around sedation to integrate into daily work, and we have reports for monitoring our processes and outcomes.” Another respondent identified “We have built into the orders the guideline for transfusion only if hemoglobin is less than 7 g/dL. This can be overridden by provider judgment. When this occurs, a chart review is completed, and the appropriateness of ordering is validated. If not, the ordering practice is discussed with provider.”
Another respondent highlighted “We have a blood transfusion protocol and if blood transfusions are ordered for patients with a hemoglobin greater than 7 it has to be signed off on by an attending physician. The pharmacists rounds with the critical care team and evaluates orders for total parenteral nutrition (TPN). There is also a protocol for nutrition and TPN is restricted for the first 7 days in the ICU. We have chest radiograph and urinalysis-ordering criteria based on evidence-based practices, and we are tracking and providing feedback on how we are doing to the clinical staff. We have reduced the average monthly urinalysis tests from over 1,500 down to 90. We presented the results of the project at with a poster presentation at a research day within our facility.”
Dissemination of the project results were reported and included posters at a variety of national meetings including the American College of Chest Physicians, American Association of Critical Care Nurses National Teaching Institute, American Thoracic Society, Society of Critical Care Medicine, American Society of Hospital Pharmacy, American Nurses Association Conference, Institute for Healthcare Improvement, Society of Hospital Medicine Annual meeting, and publications in journals including CHEST, Critical Care Medicine, AACN Advanced Critical Care, Annals of Thoracic Surgery, British Medical Journal of Quality & Safety, Dimensions of Critical Care Nursing, Heart & Lung, Journal of Critical Care, Journal of Family Medicine, Journal of Intensive Care Medicine, Journal of Pain and Symptom Management, Journal of Trauma & Acute Care Surgery, Mayo Clinic Reviews, Pediatrics, Pediatric Critical Care Medicine, Sedation & Analgesia, Southern Medical Journal, Transfusion, as well as in internal organization newsletters and quality improvement reports, and reports at internal critical care department and division meetings.
The results identify the application of the Choosing Wisely recommendations to clinical practice for critical care clinicians. Respondents identified a number of ways that the Choosing Wisely recommendations have been integrated and processes of care improved. Categories of improvement included:
- 1) Revision to order sets including in the EMR, EMR reminders for transfusion restrictions, use of checklists to reduce unnecessary diagnostic testing.
- 2) Development of specific policies or guidelines: blood transfusions, use of less volume blood draws, decreasing sedation, nutrition, palliative care triggers.
- 3) Team member education/orientation.
These results compare favorably to prior surveys conducted with clinicians with respect to awareness of Choosing Wisely. In a survey of Emergency Medicine department chairs and division chiefs in institutions with Emergency Medicine residency programs, 80% of respondents were aware of Choosing Wisely (6). However, a nationwide survey of 600 physicians conducted in 2014 and repeated in 2017 identified no significant changes in awareness of the Choosing Wisely campaign, with awareness only increasing from 21% to 25% (5). Like most protocols, guidelines and recommended improvement strategies, the Choosing Wisely campaign cannot eliminate the problems of inappropriate decisions and low clinician compliance with clinical care targets/goals. Additionally, although promoting appropriate testing that is beneficial in influencing clinical decision-making, additional efforts are needed to examine how clinical decisions are made, as limited documentation often exists on the specific and detailed reasons why decisions are made.
A significant limitation of the study was the low overall response rate (1.6% response rate of the total membership of 150,000 clinicians), and thus is it reasonable to question generalizability. However, it is important to consider that the primary intent of the survey was to characterize the various types of interventions clinicians are utilizing to address Choosing Wisely recommendations, rather than to accurately determine the actual extent of penetration of these recommendations into clinical practice. The survey did yield new information about approaches to implementation, including important exemplars. When interpreting our results, it is worth recalling that the survey was distributed by the respective organizations either via an email newsletter blast or to the individual emails of the organization’s membership. Additionally, the largest number of respondents were nurses, most likely reflecting the large membership of the American Association of Critical Care Nurses (about 115,000) compared with the other CCSC organizations (16,000–20,000).
However, although a larger percentage of nurse respondents reported not being aware of the Choosing Wisely recommendations in this survey, the original campaign was initially targeted to physician groups. There is growing awareness of the campaign among other healthcare providers including among nurses and advanced practice nurses (7).
Respondents in the current study also identified variability in the degree to which all clinicians adhere to the Choosing Wisely recommendations. Some respondents reported that only some or none of the recommendations have been implemented at their organization. This highlights the need for continued reinforcement of the benefit of the Choosing Wisely recommendations in promoting high-value care in critical care. Measures to promote clinician awareness could include sharing the results of institutional or health system initiatives aimed at implementing the Choosing Wisely recommendations, sharing “lessons learned” from teams that have successfully implemented a clinical initiative, and showcasing studies that demonstrate the cost implications of reducing unnecessary tests and procedures.
Notably, several respondents identified that a specific quality improvement or research initiative had been implemented related to the Choosing Wisely recommendations. One respondent identified that the institution reduced RBC usage by 20% and fresh frozen plasma by 80% through education, changing of order sets, policies, and feedback. Others reported that the results of initiatives had been reported internally at critical care department and division meetings, presented in poster presentations, published in organizational newsletters, or in peer-reviewed journals. This is encouraging and reflects the impact that focused efforts can have at improving care in the ICU as well as in promoting dissemination efforts.
Respondents familiar with the Choosing Wisely recommendations reported varying degrees to which the five recommendations had been implemented at their organization. Although the CCSC has promoted awareness of the critical care recommendations, ongoing dissemination is needed to ensure that all critical care clinicians are familiar with the specific recommendations for critical care. Sharing strategies for successful adoption could also be useful for clinicians. A number of examples of targeted measures for reducing unnecessary testing in the ICU have been published including unit based quality improvement projects, changing order sets, and integrating ordering guidelines into team rounds (8–11). In order to increase the benefits of the Choosing Wisely critical care list, efforts need to be deployed to encourage compliance (12). Continued education, sharing of strategies for implementation, and showcasing exemplars in critical care practice may have the greatest impact. In reflecting on the outcomes of the Choosing Wisely campaign, Kerr et al (13) outline a road map for increasing the impact of the campaign highlighting dissemination of successful approaches, measuring clinically meaningful outcomes, and continued testing of ways to raise awareness of both clinicians and patients. As collectively the CCSC represents over 150,000 critical care professionals, continuing to identify strategies for promoting the Choosing Wisely recommendations can result in impactful change to improve care in the ICU.
This article reports on the work of a Critical Care Societies Collaborative (CCSC) workgroup. The CCSC comprises the four major U.S. professional and scientific societies dedicated to the care of critically ill patients, including the American Association of Critical-Care Nurses, the American College of Chest Physicians, the American Thoracic Society, and the Society of Critical Care Medicine.
1. Morgan DJ, Dhruva SS, Coon ER, et al. 2017 update on medical overuse: A systematic review. JAMA Intern Med 2018; 178:110–115.
2. Cassel CK, Guest JA. Choosing wisely
: Helping physicians and patients make smart decisions about their care. JAMA 2012; 307:1801–1802.
4. Halpern SD, Becker D, Curtis JR, et al; Choosing Wisely
Taskforce; American Thoracic Society; American Association of Critical-Care Nurses; Society of Critical Care Medicine: An official American Thoracic Society/American Association of Critical-Care Nurses/American College of Chest Physicians/Society of Critical Care Medicine policy statement: The Choosing Wisely
® Top 5 list in Critical Care Medicine. Am J Respir Crit Care Med 2014; 190:818–826.
5. Colla CH, Mainor AJ. Choosing wisely
campaign: Valuable for providers who knew about it, but awareness remained constant, 2014-17. Health Aff (Millwood) 2017; 36:2005–2011.
6. Maughan BC, Baren JM, Shea JA, et al. Choosing wisely
in emergency medicine: A national survey of emergency medicine academic chairs and division chiefs. Acad Emerg Med 2015; 22:1506–1510.
7. Kleinpell R, Kapu A, Witherspoon B, et al. APRNs and the Choosing Wisely
® campaign. American Nurse 2017; 12:14–17.
8. Ganapathy A, Adhikari NK, Spiegelman J, et al. Routine chest x-rays in intensive care units: A systematic review and meta-analysis. Crit Care 2012; 16:R68.
9. Kotecha N, Shapiro JM, Cardasis J, et al. Reducing unnecessary laboratory testing in the medical ICU. Am J Med 2017; 130:648–651.
10. Kumwilaisak K, Noto A, Schmidt UH, et al. Effect of laboratory testing guidelines on the utilization of tests and order entries in a surgical intensive care unit
. Crit Care Med 2008; 36:2993–2999.
11. Valencia V, Arora VM, Ranji SR, et al. A comparison of laboratory testing in teaching vs nonteaching hospitals for 2 common medical conditions. JAMA Intern Med 2018; 178:39–47.
12. Angus DC, Deutschman CS, Hall JB, et al. Choosing wisely
in critical care: Maximizing value in the ICU. Chest 2014; 146:1142–1144.
13. Kerr EA, Kullgren JT, Saini SD. Choosing wisely
: How to fulfill the promise in the next 5 years. Health Aff (Millwood) 2017; 36:2012–2018.
choosing wisely; high-value care; intensive care unit; tests and procedures
Supplemental Digital Content
Copyright © by 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.